For women with complex medical needs, contraception throughout childbearing years may be essential for managing their underlying medical conditions and setting the stage for a healthy pregnancy when desired. To provide the needed expertise, the High Risk Contraception Clinic at Brigham and Women’s Hospital works with patients, often in collaboration with disease sub-specialists, to provide individualized contraceptive care within the framework of the underlying condition.

“For women with complex medical conditions, unintended pregnancy can be life-threatening and informed planning can be pregnancy-saving. But contraception as part of a care plan frequently gets overlooked and overshadowed by other needs,” said Deborah A. Bartz, MD, MPH, an obstetrician-gynecologist (OB/GYN) who staffs the clinic.

While unintended pregnancy is common among all women, it may put those who have medical complications at risk for worsening of their primary disease or for pregnancy complications including birth defects. Deliberately taking care to prevent unintended pregnancy in the setting of other medically complex diagnoses (such as hypertension, migraine disease, auto-immune disorder or substance use disorder) allows patients to optimize future pregnancy planning.

The weekly clinic in the Department of Obstetrics and Gynecology was launched in 2005 by Alisa Goldberg, MD, MPH, director of the hospital’s Family Planning Division and the two-year Family Planning Fellowship. Fellows staff the clinic under the direction of the Family Planning faculty, Drs. Goldberg, Bartz and Kari Braaten, MD, MPH.

The clinic is open to patients from throughout the community, though many are referred from the Brigham’s specialists in rheumatology, cardiology or neurology and from the congenital heart service at Boston Children’s Hospital. Patients include those with long-term chronic illnesses, such as immunological abnormality, seizure disorders or congenital cardiac defects.

Partnering with Internal Medicine Subspecialists to Provide Contraception

While OB/GYNS usually know the referral pathways to help their patients access internal medicine subspecialty care, internists and internal medicine subspecialists may be less familiar with helping their patients find contraception care, Dr. Bartz said. “Those medicine subspecialists are the people we’re really trying to partner with.”

To raise awareness of the clinic, the family planning team has led grand rounds in Brigham and Women’s Internal Medicine subspecialty departments, including Neurology and Rheumatology.

Page Pennell, MD, a leader of the Brigham’s Women’s Epilepsy Program, is a long-time partner with the clinic. She considers the expertise at the High Risk Contraception Clinic “invaluable” for her patients for both pregnancy planning and stabilizing their disease.

“It is vital that women with epilepsy have planned pregnancies to reduce the risk for adverse baby outcomes, but many of the medications we use for epilepsy interact with many contraceptives,” she said. And, because one-third of women with epilepsy have hormonally-sensitive seizures, stabilizing sex hormones can offer an additional level of seizure control as an adjunctive therapy to anti-seizure medications.

“Clinical collaboration has been able to put my mind at ease, knowing that my patients are getting the best care on a very important aspect of their overall care.”

“The providers in this clinic understand all of these critical nuances in caring for our patients and allow them to make informed choices about the use of different contraceptive treatments,” Dr. Pennell said. “Clinical collaboration has been able to put my mind at ease, knowing that my patients are getting the best care on a very important aspect of their overall care.”

The Challenges of Contraception for Patients with Complex Conditions

Resources for OB/GYNs to address complex contraception needs include the U.S. Medical Eligibility Criteria for Contraceptive Use, 2016 from the Centers for Disease Control and Prevention (CDC) and the 2019 Use of Hormonal Contraception in Women with Coexisting Medical Conditions, a Practice Bulletin from American College of Obstetricians and Gynecologists (ACOG), co-authored by Dr. Bartz.

But balancing the huge range and complexity of individualized needs with selection among various contraceptive methods can be challenging for practitioners who primarily see a healthy population. “Beyond birth control pills, when you dose some of the same hormones through the vaginal ring or through the transdermal patch, the differences in bioavailability, metabolism and in side effect profile can have a profound significance for women with chronic medical conditions,” Dr. Bartz said.

And, the risk-benefit profile varies with each patient and condition. “For some, pregnancy can be so health-altering or life-affecting, we have to consider that while the birth control might have risks, it might have a better risk profile than pregnancy itself,” Dr. Bartz said.

Patients seen at the High Risk Contraception Clinic include those with newly diagnosed or lifelong conditions who seek to initiate, switch or improve their utilization of contraception methods.

Using Contraceptive Methods for Non-Contraceptive Benefits

Family Planning physicians also work with patients whose disease process is affected by their natural hormonal cycle and for whom contraceptive medications may improve their primary disease.

For example, some women’s migraine disease or seizure disorders are hormonally influenced. Some women’s health neurologists and other subspecialists at Brigham & Women’s may be comfortable prescribing an initial contraceptive method for symptom control, but then turn to the High Risk Contraception Clinic to seek alternatives if needed. The clinic staff also uses contraceptive methods to treat heavy, irregular or painful periods that are sometimes exacerbated by a patient’s primary medical condition.

“There are a lot of nuances to the various formulations of birth control pills alone and how hormonal pill dosing can be manipulated to affect a patient’s symptoms,” Bartz said. “It demonstrates the need for subspecialists in complex family planning.”

How a Community OB/GYN Practice Can Provide Contraception Care for Medically Complex Patients

Even without a fellowship-trained complex family planning subspecialist, Dr. Bartz said, an OB/GYN practice can address contraceptive needs of medically complex patients. Initial steps can include:

• Designating one physician to champion medically-complex family planning as a niche within the practice and become a resource for colleagues
• Partnering with medicine subspecialists in your community. When treating the same patient, create opportunities for back-and-forth conversation about what various birth control methods might mean for the patient.
• Advocating with other physicians that pregnancy prevention or planning should be part of a patient’s care plan when a new diagnosis is made

“This has very broad applicability to a large number of patients,” Bartz said. “Our goal is to enable patients to easily access the contraceptive options that best suit both their family planning and medical needs.”